Objective

To evaluate the effectiveness of the BREATHE intervention for mental health clinicians, compared with a training in motivational interviewing (MI), in reducing clinician burnout and improving patient-centered care and patient health

Study Design

Design Element	Description
Design	Randomized controlled trial
Population	192 mental health clinicians and 470 adult patients from 2 community mental health centers
Interventions/ Comparators	BREATHE intervention, which teaches clinicians strategies to help reduce burnout MI training, which teaches clinicians technical skills for implementing patient-centered care
Outcomes	Primary: clinician burnout Secondary: clinician job-related well-being, clinician and patient perception of quality of care, patient perception of patient-centered care, patient confidence for mental health management, patient satisfaction, proportion of appointments kept, medication adherence, patient health and mental health outcomes
Timeframe	12-month follow-up for primary outcome

This randomized controlled trial examined whether a program to reduce burnout among mental health clinicians, called BREATHE, would also improve patient-centered care and health outcomes. BREATHE stands for Burnout Reduction: Enhanced Awareness, Tools, Handouts, and Education.

The study included mental health clinicians and their adult patients. Participants were from one urban health center in St. Louis, Missouri, and one rural health center in Logansport, Indiana. Both centers provided substance abuse and mental health services. Of the 192 clinicians in the study, 84% were white and 80% were female. Of the 470 patients, 52% were white and 48% were female. In addition, 70% of patients had completed at least high school, and 87% were unemployed. The mean patient age was 45.

Researchers randomly assigned participating clinicians to one of two groups. Clinicians in the BREATHE intervention group received training to reduce burnout using mindfulness, healthier thinking strategies, boundary setting, social support mobilization, and relapse prevention. The training used a group workshop format. Clinicians in the BREATHE group also received materials designed to help them identify burnout signs and triggers and develop ongoing self-care. The second group of clinicians received training in MI, a patient-centered therapeutic approach to help patients set their own goals for care. The researchers included the MI group as a control group that would also potentially improve patient-centered care and patient health. The research team randomly invited patients from the caseloads of participating clinicians to take part in the study.

Clinicians completed surveys at baseline, and then at 3, 6, and 12 months after baseline. Researchers interviewed patients at baseline and at 6 and 12 months after baseline.

Patients and clinicians provided input on the research design and helped interpret the results.

Results

Researchers found no significant differences between the clinicians in the BREATHE and MI groups for any of the clinician outcomes. In addition, clinicians in the BREATHE group did not show significant improvement in burnout or any of the secondary clinician outcomes compared to baseline.

Over the course of the study, patients associated with a clinician in the BREATHE group showed higher medication adherence (p=0.04) and larger decreases in patient perception of patient-centered care (p=0.05) compared with patients of a clinician in the MI group. Researchers found no other significant differences between the two patient groups. However, patients in both groups showed significant improvement in confidence for managing mental health, satisfaction with care, as well as mental and physical health outcomes, including depression and anxiety.

Limitations

Participating clinicians reported low levels of burnout at the beginning of the study, limiting the ability of the researchers to determine the effectiveness of the BREATHE intervention for reducing burnout. In addition, 37% percent of clinicians did not complete data collection at all three time points, primarily because they left the organization. This turnover may have made it more difficult to find differences between groups. The study included clinicians and patients from only two mental health centers in two geographic locations, limiting the generalizability of the findings to other settings and locations.

Conclusions and Relevance

The BREATHE program did not reduce clinician burnout and was not more effective than MI training for reducing clinician burnout or for improving patient-centered care or most patient outcomes.

Future Research Needs

Future studies could seek to identify the most effective ways to reduce burnout among mental health clinicians. Researchers could also identify and work with mental health clinicians most in need of interventions to address burnout.